Prescription Coverage Comparison
|
Option A¹ |
Option B |
Option B with HDHP |
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|---|---|---|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
|
Annual Deductibles and Out-of-Pocket Maximums |
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| Deductible (Individual/Family) | N/A | N/A | N/A | N/A | $2,000/$4,000² | $4,000/$8,000² |
| Out-of-Pocket Maximum (Individual/Family) | $2,650/$5,300 | $2,650/$5,300 | $3,300/$6,600 | $3,300/$6,600 | $4,000/$8,000 | $8,000/$16,000 |
|
Copay/Coinsurance: In-Network Retail (up to 30-day supply) |
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| Generic (automatic substitution) | $10 | Reimbursed at contracted in-network rate minus the in-network copay³ | $5 | Reimbursed at contracted in-network rate minus the in-network copay³ | $5 | Reimbursed at contracted in-network rate minus the in-network copay³ |
| Brand — Preferred | $25 | You pay 50% ($200 maximum) | You pay 50% ($200 maximum) | |||
| Brand — Non-Preferred | $40 | You pay 100% | You pay 100% | You pay 100% | You pay 100% | You pay 100% |
| Specialty⁴ | $100 | N/A | $200 | N/A | $200 | N/A |
| Specialty: Prudent Rx Eligible⁴ | 30% coinsurance for eligible Prudent Rx specialty; $0 when enrolled in Prudent Rx | N/A | 30% coinsurance for eligible Prudent Rx specialty; $0 when enrolled in Prudent Rx | N/A | 30% coinsurance for eligible Prudent Rx specialty; $0 when enrolled in Prudent Rx | N/A |
|
Copay/Coinsurance: Mail Order Service or Maintenance Choice (up to 90-day supply) |
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| Generic (automatic substitution) | $20 | N/A | $10 | N/A | $10 | N/A |
| Brand — Preferred | $50 | You pay 50% ($400 maximum) | You pay 50% ($400 maximum) | |||
| Brand — Non-Preferred | $80 | You pay 100% | You pay 100% | |||
¹Caremark Option A is frozen to current enrollees. If you elect to change out of the plan, you will not be able to re-enroll in it.
²The full family deductible must be met before any family member has costs shared by the medical or prescription plans. Medical and prescription costs both count toward the shared deductible of this plan.
³Out-of-network pharmacies may bill you in excess of the plan's in-network rates of reimbursement.
⁴Specialty drugs must be filled through the CVS Specialty Pharmacy.